Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy.

BACKGROUND: The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy. METHODS: Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay. RESULTS: Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028). CONCLUSION: This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm.

The authors present a case report of a 79-year-old man with insufficient cardiac contractile function who underwent endovascular stent-grafting for an abdominal aortic aneurysm. Thirty months later, the aneurysm ruptured into the inferior vena cava and subsequently formed an aortocaval fistula caused by migration of the stent-graft. Urgent secondary endovascular stent-grafting successfully excluded the blood flow into the vena cava. Endovascular stent-grafting is deemed suitable for treating this serious disorder, especially in severely debilitated or compromised patients who might not withstand a standard surgical intervention. Furthermore, in patients with previous stent-grafting, since the primary stent-graft makes repair by open surgery more difficult, a secondary endovascular intervention is recommended if feasible.

[Aortic valve repair and patch closure for unruptured aneurysm of non-coronary sinus of valsalva with aortic regurgitation].

The patient was a 53-year-old woman who complained of chest pain. Echocardiography and angiography revealed mild aortic regurgitation (AR) with an eccentric jet and an unruptured aneurysm of the non-coronary sinus of Valsalva which protruded into the left atrium. Operative findings showed that tethering due to elongation of the circumference of the aortic wall at the level of the non-coronary sinus commissures caused AR. Then patch closure and partial sino-tubular (ST) junction plication were carried out. Postoperative echocardiography showed decrease of AR and complete repair of the aneurysm of Valsalva sinus.

Pharmacological brain cooling with indomethacin in acute hemorrhagic stroke: antiinflammatory cytokines and antioxidative effects.

We evaluated the effects of a novel pharmacological brain cooling (PBC) method with indomethacin (IND), a nonselective cyclooxygenase inhibitor, without the use of cooling blankets in patients with hemorrhagic stroke. Forty-six patients with hemorrhagic stroke (subarachnoid hemorrhage; n = 35, intracerebral hemorrhage; n = 11) were enrolled in this study. Brain temperature was measured directly with a temperature sensor. Patients were cooled by administering transrectal IND (100 mg) and a modified nasopharyngeal cooling method (positive selective brain cooling) initially. Brain temperature was controlled with IND 6 mg/kg/day for 14 days. Cerebrospinal fluid concentrations of interleukin-1beta (CSF IL-1beta) and serum bilirubin levels were measured at 1, 2, 4, and 7 days. The incidence of complicating symptomatic vasospasm after subarachnoid hemorrhage was lower than in non-PBC patients. CSF IL-1beta and serum bilirubin levels were suppressed in treated patients. IND has several beneficial effects on damaged brain tissues (anticytokine, free radical scavenger, antiprostaglandin effects, etc.) and prevents initial and secondary brain damage. PBC treatment for hemorrhagic stroke in patients appears to yield favorable results by acting as an antiinflammatory cytokine and reducing oxidative stress.

An electric cutter for all surgical prostheses.

A new electric cutter for surgical prostheses has been developed and was compared with surgical scissors for efficacy. This comparison of the two methods was done by cutting the edges of nine popular prostheses. It was concluded from gross and microscopical results after pulling both edges of the grafts cut by the two methods that the electric cutter is much more effective for surgical prostheses.

Influence of pulmonic position on durability of bioprosthetic heart valves.

BACKGROUND: The insertion of bioprosthetic valves into the pulmonic position is not performed commonly because of uncertainty concerning the necessity and durability of such valves. METHODS: We reviewed the long-term outcome of 10 patients who underwent pulmonary valve replacement with bioprostheses between March 1985 and March 1997. A Carpentier-Edwards supraannular bioprosthesis was used in 7 patients, a Hancock II bioprosthesis was used in 2 patients, and a Carpentier-Edwards pericardial bioprosthesis was used in 1 patient. The mean patient age at the time of pulmonary valve replacement was 38.9 +/- 16.3 years (range, 15 to 63 years). The diagnoses were pulmonary valvular regurgitation after corrective surgery for tetralogy of Fallot in 7 patients, right ventricular outflow tract stenosis and absent right pulmonary artery combined with a double-outlet right ventricle in 1 patient, pulmonary valvular regurgitation with pulmonary artery dilatation in 1 patient, and aortic valve stenosis treated with our modification of the Ross procedure using a pulmonary bioprosthesis in 1 patient. Survivors were followed up for a mean of 5 years and 5 months. RESULTS: One patient underwent reoperation because of infective endocarditis of the bioprosthesis. No bioprosthetic valve dysfunction has been observed on Doppler echocardiography during a maximum follow-up period of 12.2 years, except in the patient who underwent replacement at 15 years of age. CONCLUSIONS: Bioprostheses in the pulmonic position are durable in adult patients because they face a minimal hemodynamic load, but they may undergo early leaflet degeneration in younger patients.

Successful repair of coronary artery-coronary sinus fistula with aneurysm in an adult.

We report a very rare case of an adult with coronary artery fistula and aneurysm formation. This fistula was successfully closed with direct suture closures by opening the aneurysm under complete cardiopulmonary bypass. The distal terminated orifice of the fistula, which drained to the coronary sinus, was also closed. Finally, aneurysmorrhaphy with overlapping mattress sutures was performed. The postoperative angiographic study demonstrated normal coronary artery distribution, and the patient was asymptomatic without recurrence at 2 years after the operation.

Vascular orientation by intra-arterial dye injection during spinal arteriovenous malformation surgery.

OBJECTIVE: Rich and complicated vascular structures on the spinal cord often interfere with obliteration of a spinal arteriovenous malformation (AVM). Vascular orientation during spinal AVM surgery is essential. The authors recently performed six consecutive spinal AVM surgeries in five patients (two with perimedullary AVMs, and three with dural arteriovenous fistulae) with the aid of intra-arterial injection of dye (indigo carmine). METHODS: Two representative cases are described. A microcatheter was placed preoperatively in the artery of interest. Subsequent to the exposure of the vascular complex, a 1-ml injection of indigo carmine (2 mg/ml) clearly demonstrated the feeding arteries and the draining veins around the AVM or dural arteriovenous fistula. RESULTS: One patient had repeat surgery because of incomplete obliteration of the AVM owing to migration of the catheter. All patients, except one who had temporary postoperative deterioration and persistent neurological deficits, had good surgical outcomes, however. No apparent side effects caused by the dye were reported. CONCLUSION: The assistance system for spinal AVM surgery is easy and safe and can be applied in other surgical institutions.

Transcallosal interforniceal approach for a posteriorly projecting high basilar bifurcation aneurysm. Case report.

A transcallosal interforniceal approach was used for treatment of a posteriorly projecting high basilar bifurcation aneurysm with a neck located 30 mm above the posterior clinoid process. The aneurysm was successfully clipped via the third ventricle with minimal neurological deficits. This approach appears to be appropriate for basilar bifurcation aneurysms located more than 20 mm above the posterior clinoid process when the fundus projects posteriorly, and permits direct visualization of the aneurysmal neck and vital perforators with minimal brain retraction.

Liposteroid therapy for refractory seizures in children.

Liposteroid is dexamethasone palmitate incorporated into liposomes and was developed as an anti-inflammatory drug for targeting therapy mainly for rheumatoid arthritis. Recently, it was reported that liposteroid might be effective for the treatment of West syndrome, with fewer side effects than those of corticotropin therapy. We describe three patients, a 2-month-old boy with early infantile epileptic encephalopathy, a 4-month-old girl with symptomatic West syndrome, and a 2-year-old girl with symptomatic localization-related epilepsy, whose refractory seizures were treated with liposteroid according to the original method reported by Yamamoto and colleagues in 1998. Uncontrollable seizures ceased completely in two patients and the seizure frequency decreased markedly in the other patient. Electroencephalograms revealed marked improvement in all patients. They showed no relapse of the seizures, and all showed no adverse effects except for mild brain shrinkage in one patient. Our experience with these three patients suggests that liposteroid therapy might be a new option for the treatment of refractory seizures in children, as well as for West syndrome.

Mucocele-like formation leading to neurological symptoms in prolactin-secreting pituitary adenomas under dopamine agonist therapy.

BACKGROUND: Mucocele-like formation associated with pituitary adenomas, to the best of our knowledge, has been paid little attention. We report three adult male patients with a mucocele-like formation that developed behind the tumor and led to neurological symptoms in prolactin-secreting pituitary adenomas (prolactinomas) under dopamine agonist therapy. CLINICAL PRESENTATION: Three adult male patients with prolactinomas developed hyperprolactinemia and new neurological symptoms during dopamine agonist treatment. In each case, the pathogenesis of these symptoms was due in part to a mass enlargement with development of a mucocele-like formation behind a prolactinoma. In our patients, a prolactinoma with a suprasellar extension originally filled the sphenoid sinus. When dopamine agonist therapy became ineffective, new symptoms, such as progressive visual impairment other than typical hemianopsia or headache, developed and mass enlargement was found on MRI. MRI demonstrated two different components: an enhancing prolactinoma and a nonenhancing mucocele-like formation behind the tumor. Two patients had compression of the optic nerves by a mass. Transnasal removal of mucoceles and adenomas led to resolution of the neurological symptoms. CONCLUSION: Early suspicion of a mucocele-like formation under dopamine agonist therapy for prolactinomas is important in order to avoid a delay in surgery, because a change in medical treatment will be ineffective.

Posttraumatic edema in the corpus callosum shown by MRI.

MRI was performed on 120 patients who sustained closed head injury of varying severity. Patients ranged in age from 4 to 87 years (average, 32 years). All patients had an initial MRI within 28 days (median 12 days) of injury. MRI disclosed areas of abnormal signals in the corpus callosum of 21 (18%) of the 120 patients; 1 (2%) of the 44 patients who sustained mild injuries (GCS > or = 13), 3 (10%) of the 31 moderate injuries (GCS 9-12), and 17 (38%) of the 45 severe injuries (GCS < or = 8) (p < 0.0001). All but 2 of the 21 patients with corpus callosum lesions had other parenchymal lesions that were visualized by MRI. Of these 21 patients, MRI was repeated in 19. In 13 of the 19 patients, repeat MRI scans at 25 to 42 days after injury showed the disappearance of lesions that had on the first MRI shown a high signal on T2-weighted and FLAIR images and a normal signal on T1-weighted images. The MRI findings and time source of the disappearance of the corpus callosum lesions mirrored those of paracontusional edema in the subcortical white matter. Patients in whom the corpus callosum lesion disappeared had a better outcome than those in whom the lesion remained (good recovery/moderate disability; 92% vs 63%). The present MRI results suggest that some lesions in the corpus callosum following closed head injury are reversible, thus resembling edema that may be produced by a relatively mild shear strain force to the corpus callosum.

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

Trigeminal neuralgia associated with tentorial agenesis and temporal lobe herniation--case report.

A 22-year-old female presented with an extremely rare case of trigeminal neuralgia associated with tentorial agenesis. The pulsating pain in her left maxillary region persisted for an abnormally long time and had no trigger zone. The pain later spread to the periorbital region. Coronal magnetic resonance imaging revealed left medial temporal lobe herniation caused by tentorial agenesis. The herniated temporal lobe, which had distorted the superior cerebellar artery, was causing compression of the trigeminal nerve. Her condition improved following microvascular decompression surgery. Tentorial agenesis should be considered as a cause of atypical pulsating facial pain, especially in younger patients.

Staged transsphenoidal surgery for fibrous nonfunctioning pituitary adenomas with suprasellar extension.

Staged transsphenoidal surgery was performed in seven patients with nonfunctioning pituitary adenomas with suprasellar extension. Remnant adenomas were present in a supersellar position after complete removal of the intrasellar tumor, and did not descend into the sella because of the fibrous nature in five patients or fibrous nature and dumbbell shape in two. Magnetic resonance images were obtained every 2 weeks following initial surgery. The suprasellar residual adenomas descended into the sella within 2 months in six patients and 1.5 months in one patient. A second transsphenoidal operation was performed 2 months following the initial procedure in four patients, 3 months in one, and 5 months in two. In six of the seven patients, extensive tumor removal was achieved safely and easily by the staged approach. Patients were followed up over 6 to 58 months (mean +/- SD 24.7 +/- 18.9 months). There were no major surgical complications or recurrence of tumor on follow-up images. Our postoperative imaging studies and surgical results demonstrated that staged transsphenoidal surgery is an effective and safe treatment for fibrous nonfunctioning pituitary adenomas with suprasellar extension.

[Clinical evaluation of Dumon stent for tracheobronchial stenosis due to advanced esophageal carcinoma].

We inserted Dumon stent to 13 patients with tracheobronchial stenosis due to advanced or recurrent esophageal carcinoma. Severe dyspnea was improved in 11 patients except for 2 patients with bilateral recurrent nerve palsy. 3 cases who had radiation therapy or chemotherapy lived over 150 days. We inserted esophageal stent in 4 cases. 2 patients died due to hemoptysis after 156 days and 35 days. We conclude that Dumon stent is one of the useful treatments in order to improve quality of life and prognosis of advanced or recurrent esophageal carcinoma.

[A study of serum levels of cefoperazone sodium and its movement to myocardial tissue].

After introduction of anesthesia to 19 patients requiring cardiac surgery, cefoperazone sodium (CPZ) 1 g was administered intravenously and its movement to serum, pericardial fluid and tissue of the right auricle was studied. The serum CPZ level was 75.68 micrograms/ml and 59.77 micrograms/ml at 60 and 120 minutes after administration, respectively, and the biological half-life time was 2.54 hours. Lengths of time to achieve peak concentrations of CPZ in pericardial fluid and right auricle tissue after administration were both approximately 1 hour. The drug level in myocardial tissue was 14.52 micrograms/g after 240 minutes. Level of CPZ in myocardial tissue was maintained, even after 240 minutes, sufficiently higher than MIC80 of the drug against Gram-negative bacilli which may be responsible for many infections. No side effects were observed in any case examined.

[A clinical study of transfer of cefminox and piperacillin into pulmonary tissue].

Serum concentrations of cefminox (CMNX) and piperacillin (PIPC) and their transfer into pulmonary tissue during surgery were serially studied following 1-hour intravenous instillation of 1 g of CMNX or PIPC immediately before thoracotomy, and the following results were obtained. Maximum serum concentrations of CMNX and PIPC were observed 1 hour after the commencement of administration, and their levels gradually decreased thereafter. The mean peak level of CMNX was 72.21 micrograms/ml, and T 1/2 was 1.62 hours. The mean peak level of PIPC was 43.26 micrograms/ml, and T 1/2 was 1.54 hours. In the pulmonary tissue, mean concentrations of CMNX in the normal pulmonary (alveolar) tissue were 28.80, 26.50 and 17.80 micrograms/g at 2.5, 3 and 4 hours, respectively, after the commencement of administration, and the corresponding levels for bronchiolar tissue were 19.6, 18.40 and 20.53 micrograms/g, respectively. The mean concentrations of PIPC in the normal pulmonary (alveolar) tissue were 18.97, 7.34 and 5.0 micrograms/g at 2, 3 and 4 hours, respectively, after the commencement of administration, and the corresponding levels for bronchiolar tissue were 7.2, 9.20 and less than 0.2 micrograms/g, respectively. PIPC also showed favorable transfer into the hilar lymph node tissue and obstructive pneumonitic lesions. The transfer of both drugs into pulmonary tissue suggests that both drugs are useful for the treatment of respiratory infectious diseases and the prevention of postoperative infections.

[A clinical study on pulmonary tissue uptake of flomoxef].

Based on the results of a study on pulmonary tissue uptake of flomoxef (FMOX), a new antibiotic agent, in 45 patients undergoing thoracotomy, the following conclusions were drawn: 1. Immediately preoperative 1 hour-drug infusion of 1 g FMOX led to maximum serum concentration (averaging 42.4 micrograms/ml) 1 hour later, with a half-life of its beta phase of 1.26 hours. 2. Normal lung (alveolar) tissue concentration was Cmax 17.98 micrograms/g with its ratios to serum peak value being 31.8, 27.1, 22.2, 9.4, 5.9 and 5.0% at 1, 2, 3, 4, 5 and 6 hours later, respectively. 3. Bronchiolar tissue concentration was Cmax 31.91 micrograms/g, with its ratios to serum peak value being 27.8, 19.3 and 10.1% at 2, 3 and 4 hours later, respectively, indicating its good bronchiolar intra-tissue transition. The above results suggested the usefulness of FMOX for both the treatment of respiratory infections and the prevention of postoperative infections.

[Transfer of cefmenoxime to lung tissue and thoracic muscle in thoracic surgery].

Twenty patients who were performed pulmonary resection for the disease of the lung were administered 2 g of cefmenoxime (CMX) intravenously during the operation. The CMX levels in serum, lung tissue and thoracic muscle were measured by agar-well technique. The CMX levels in lung tissue and thoracic muscle were higher than the MIC80 of CMX for Klebsiella pneumoniae, Haemophilus influenzae and Streptococcus pneumoniae which were commonly as isolated causative organisms from the patients with pulmonary infection. These results indicate that CMX will be useful agent for the prevention and treatment of pulmonary infection.